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State of California-California Agency Depart. 4 of Toxic SobstanM Control-(HSS <br /> P.O.Box 806 <br /> Sacramento,CA 958124" <br /> California Hazardous Waste Permanent ID Number Application <br /> Please type or neatly print in ink Please review the line-by-line to owtions caefully. <br /> To check on the status of your request,go to www.hMqs&sg.qa.&gv and click on Reports. <br /> New Namber ReagesLs• Check all that apply. (See instructions) <br /> 14 1. I am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑Transporter <br /> Reason for new number: A. O Never had a number B. ❑ Business moved C. )0 Legal owner of business changed <br /> If your business generates greater than 100 kg of RCRA hauwdour waste per month,contact US EPAfor a federal ID number. <br /> Chaeees to Staten or Information for an Fair m NMPher (See instrucoom) <br /> For existing ID number- C A L O 0 () _L q -1 4- z <br /> ❑ 2. 1 am updating the mailing address and/or contact information only. <br /> ❑ 3. 1 am inactivating this ID Number. <br /> ❑ 4. 1 am reactivating this ID Number. <br /> ❑- 5. 1 am changing the business name. There has been no ownership change. <br /> �'q.,/� Q <br /> 6. Site/FacilityBushmms Name(Include DBA.):-I.IJr1 Uu I'U'D <br /> 7. She Location: W- W . r l a rr`;Q ,► llt <br /> ,e -i) at*on GFS 0(52D4 Sin (Jc�c�u;n <br /> City state Zip county <br /> 8.(a)Federal Employer ID Nmnber. (b)Board of Equalization Fee Amount Number <br /> - <br /> (b) <br /> (b)iist only requiredfrom genernton ofgreater than S tau per ealendv year.) <br /> 9. Mailing Address: <br /> ZA4 W . 4+- , /(}I;rvA Wal <br /> (See instruclionr.) <br /> -foci -bn cA g520 <br /> City State Zip <br /> �All�i r Ch cl h a (.See instructionsLast Name <br /> .' <br /> 10. site Conrad person: vet <br /> Contact Person Address: FE 1 <br /> 5an�n CA q-5(n(v <br /> City Stattee zip <br /> CmtactPerson Phone Number: 17 41 -04 TI Fax Number: (.LXn�/1 <br /> Area Code Phone Number Arm Cade Fax Number <br /> Contact Person Business Email Address <br /> Preferred Primary Communication: Mail ❑ Email <br /> 11. _l -_.Iud I tf 5 G• (See inswctioro.) <br /> Legal Business Owner(not owner):��/n. <br /> nJ <br /> Owner Address: 30 W- [�Qa) 9!ame 1 I-cern-an CA 045�fk <br /> sof�� /'�/�p Q Ivy city state zip <br /> Owner Phone Number. (�✓ 1 q u- uOA Fax N.W. (.�Q� 9Yg;-e, <br /> Area Code Phone Number Area Code Fax Number <br /> 12, Standard Industrial Classification(SIC)Code for the Sik: (4-D*k-D'' Number) (See iruauctioru.) <br /> DISC Form 1359(7/06) www.dtsc.ca gov <br />